Various Demographic Area Pretesting Activities

Questions for automated Be Counted Form

1. Were you already counted in the 2012 Census?

   1. Yes

   2. No

   3. Don’t know

2. What was the physical address where you were living or sleeping on January 15^st 2012?

***If you do not know the exact address, please write as much information as you know: name of street intersection, name of park, shelter or soup kitchen …***

3. On January 15, 2012, were you experiencing homelessness?

   1. Yes- Question 5

   2. No- Question 4

4. Were there any other people who lived at this address on January 15^th?

   1. YES - Are you completing this form for…

      1. ALL of them?

      2. SOME of them?

      3. Just yourself?

   2. No

5. Please list the names of all the people who live or stay with you that you believe weren’t counted in the 2012 Census.

Gather names

If 3=yes OR 4=b, then skip to 10.

6. There are certain types of people that are sometimes left off the census. Were there any additional people staying with you on January 15^th that you didn’t think of, for example:

1. Babies? Y N

2. Foster children? Y N

3. Any other relatives? Y N

4. Roommates or people not related to you? Y N

Yes for any – What is that person’s name? Anyone else?

No for all– Continue

7. Was there anyone else staying with you on January 15^st who had no permanent place to live?

Yes– What is that person’s name? Anyone else?

No – Continue

8. Was there anyone else who usually lives or stays with you but was away on January 15, 2012?

Yes– What is that person’s name? Anyone else?

No – Continue

9. Was there anyone else living or staying with you on January 15^st who is no longer living? here?

Yes – What is that person’s name? Anyone else?

No – Continue

10. … Demographics…

11. Some people live or stay in more than one place and we would like to make sure everyone is only counted once. Besides the address that you already provided…

12. If there are people 18 or under Do you/anyone sometimes live or stay somewhere else with a parent, grandparent or other person?

Yes – if more than one person in household – Who sometimes lives or stays somewhere else?

• No -

13. Do you/anyone sometimes live or stay at another home, like a seasonal or second residence?

-Yes – if more than one person in household – Who sometimes lives or stays somewhere else?

-No

14. If there are people ages 18-25 In January, (Were you/ was anyone) living in college housing – on or off campus?

• Yes – if more than one person in household – Who was living in college housing?

• No -

15. If there are people ages 18-60 In January, (Were you/ Was anyone) living or staying away for the military or for a job?

• Yes – if more than one person in household – Who was living or staying away?

• No

16. In January, (were you/ was anyone) in a place like a nursing home or a group home?

• Yes – Who was away?

• No

17. In January, was anyone in a jail or prison?

• Yes – Who?

• No

For those with another address:

18. What was your/NAME’s other address(es)? Get as many addresses as they need to provide

19. Around January 15, 2012, where did NAME live and sleep most of the time?

Fill all addresses as choices

20. On January 15, 2012, where was NAME staying?

Fill all addresses as choices

21. What address would you/NAME consider your/his/her permanent or official address?

Fill all addresses as choices

22. What is your telephone number?

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